Claims Adjuster

lllawnchair

Tallahassee, FL

Female, 27

I worked at an insurance company, in claims, from March of 2011 to August 2013. (I'm now back in grad school) I've got experience determining liability (or fault) in 7 states in the southeast US, as well as injury (Personal Injury Protection or PIP) claims in Florida.

**Disclaimer!** I am NOT qualified to give legal advice, so don't ask!

Ask me anything!

What do YOU do?

Thanks for answering my first question and for doing this Q&A! Do insurance companies ever hire private investigators to spy on a person to see if he's just faking his injury to get a settlement?

Asked by Jackie about 5 years ago

Hi Jackie!

As far as I know (I've only worked for 1 insurance company to date), most insurance companies have a special invesigation unit for claims in which they suspect foul play of some sort. This unit is usually comprised of retired police officers, detectives, that kind of thing. If an insurance company suspects that a claimant is exaggerating or faking an injury, I have heard of the adjuster referring the claim to that special unit to do surveillance on the claimant to see how their supposed injury truly affects them when they go about their day to day business. Have I every had a claim like that? no. But I have heard of it.

Even though I assume insurance companies can't charge different rates to people of different races, are stats kept internally on that stuff, and care to share to confirm / dispel some, um, common stereotypes?

Asked by TonyTony about 5 years ago

Hey Tonytony!

I, personally, have never heard of that. The premium a driver is charged is determined by a myriad of factors: the state they live in, their driving history, whether they have a loan out on their vehicle, among many other things.

And as far as stereotypes go, in auto accidents I don't believe in them anymore, haha. Sometimes everyone's a crappy driver.

Is that explanation Ed Norton's character gives in Fight Club about how car makers determine whether they'll do a vehicle recall accurate? (That they'll leave an unsafe car on the road if the recall would cost more than paying the injury claims?)

Asked by 1strule about 5 years ago

Hi 1strule,

As much as I hate to admit it: I have absolutely no idea. I've only ever handled personal lines insurance claims, and it sounds like this one falls totally outside my area of experience. I would imagine an adjuster who works in commercial claims would have a better idea of whether or not thats true, but all my colleagues are in the same boat as me.

My gut tells me, however, that that is either exaggerated or totally false. Injury claims are biiiiiiggggg liabilities, whether its a personal or commercial auto policy.

Will your employer scrutinize your work if they think you're approving too many claims? Surely they must have an idea of the approx percentage of claims that get denied for legitimate reasons, so do they use that to monitor adjusters?

Asked by Derelict about 5 years ago

Hi Derelict,

Like most industries our work is regularly evaluated and monitored by management. The computer program in which I handle claims has an automated notification system for my manager to follow up on my files every once and a while (injury claims stay open a pretty long time, non injury ones usually close relatively quickly).

In addition to that regular follow up system, once a quarter my manager randomly selects a handful of my previously closed files and reviews them for what my company calls "best claims practices". Basically she reviews my stuff to make sure I did everything I was supposed to. Aaaand then we'll have a meeting to discuss them, compliment sandwich style, if ya knowwaddamean :)

Are there some cases where NO ONE'S at fault? Say an airplane part falls from the sky, a car swerves to avoid it, and hits another car. Complete freak accident / no way to foresee. Does the US insurance system REQUIRE the assignment of SOME fault?

Asked by Tif718 about 5 years ago

The short answer? It depends...

This is where you get into the territory of difference of opinion between adjusters. Some would say that even though it's not that first car's fault that some random object same into their path, they were still negligent in that they failed to maintain control of their vehicle and hit the other car. And how would you feel if you were in that second car? There you are just driving along when this other car comes out of nowhere and damages your vehicle. And if the adjuster assigned to your claim says, well, in this case no one's at fault, it was a freak accident, you're still stuck using your collision coverage to get your vehicle fixed, and you still have to pay your deductible, even though you contributed in no way to this accident!

That being said, there are some claims in which no one is at fault, but these are claims that usually fall under comprehensive coverage: you hit a deer, or hail damages your vehicle. When a claim like that is assigned to us we don't label any party at fault (although I have jokingly assigned 100% fault to the deer before. Oh that's right, we're a bunch of cut-ups in the insurance biz, haha). But as you may have gleaned, neither of those examples involve 2 vehicles.

Now that I think of it, there is one other example I can give you: it's called the 'act of God' defense. This doctrine usually applies to property claims: i.e. a big ass storm comes through your 'hood, and a tree on your property falls into your neighbor's yard and damages their fence/shed/whatever. When that claim gets filed with your insurance, we work to determine whether that tree was healthy prior to it falling, and if it was diseased, whether you as the insured knew it and neglected to take care of the hazard on your property. If that tree had green leaves, was totally healthy, then we would deny liability to your neighbor's damage. In short, it was an "act of God" that that tree fell, there was no way to foresee on the insured's part.

If there's a rear-end collision, is the driver in the back automatically liable? Can "the guy in front of me stopped too suddenly" ever be a legitimate excuse?

Asked by JessP about 5 years ago

Well, I can never say 100% YES, every single time! But honestly? 99 times out 100, yeah, I've assigned 100% liability to the rear vehicle. Why? Well, because technically if you were maintaining a safe distance for conditions, you should have been able to stop in time to avoid the collision. What if the guy in front of the front car stopped suddenly? And they were able to stop but you were not?

When two drivers both do something wrong - let's say one runs a red light, but the other guy is driving 100mph, who is at fault? Don't some States have a system where you're not allowed to divvy fault up, but it's all or nothing by law?

Asked by DomNJ about 5 years ago

Hi DomNJ! What you're talking about is a negligence doctrine, which varies by state. In the state of Florida (as well as Kentucky and Mississippi) we have whats called "pure comparative": after a liability adjuster completes their investigation, they divide up fault by percents (although a lot of the time it's 100% one person's fault or the other, or 50/50) In Florida, what percentage you're found NOT at fault, thats the amount of your damages you can get back (or subrogate) from the other party (usually via their insurance company). So, lets say that you are in an accident in which you're found 50% at fault. This means that you can get back 50% of your damages back from the other insurance company (50% of your deductible, and then your insurance company can pursue to get 50% back of what they paid to repair your car).

here are some other negligence doctrines:

Contributory: Alabama. If you contributed at all, even 1%! to the accident, you are barred from recovering any of your damages. Sorry, Charlie.

"Not as great as": Geogia, Tennessee, Arkansas: If you are 50% or more at fault, you're outta luck. 49% or lower though, and you can pursue for reimbursement.

Those are the main ones I'm familiar with from working in the southeast,